interviews
Managing The Unavoidable
by Michael Brumage
April 1, 2020
This interview with Michael Brumage, the Medical Director of Cabin Creek Health System and Program Director of Public Health/General Preventive Medicine Residency at WVU School of Public Health, was conducted and condensed by frank news.
frank: Thank you for speaking with us Michael. Will you tell us about your background?
Michael Brumage: My name is Michael Brumage, I'm an MD and I have a master's in public health. Currently I'm the medical director for Cabin Creek Health Systems. I'm also the program director for the general preventive medicine residency at West Virginia University in the school of public health.
I am a native West Virginian. I went to undergraduate and medical school at West Virginia University.
How did you get your start working on pandemics?
I started by working in internal medicine for the United States Army and later became a preventive medicine physician. From 2005 to 2007, I was the chief of preventive medicine at Tripler Army Medical Center in Honolulu. While I was in that job, I wore two other hats, one as the public health emergency officer, PHEO, for the Pacific Regional Medical Command, and PHEO for Joint Task Force-Homeland Defense, which covered all the U.S.-affiliated islands in the Pacific. I was up to my neck in pandemic planning.
At the time we were planning for Influenza A H5N1, the “bird flu”, the highly pathogenic avian influenza we worried would become the next pandemic virus. Fortunately, it never acquired the characteristics to spread easily from person to person. While it had a very high mortality rate, it didn’t spread easily. I understood what was at stake from the very beginning of this current pandemic.
This has transpired, largely as I hoped it would not.
How so?
I had hoped that our government would have been more proactive in seeing the danger and expressing that to the American people, and that did not happen. Now we have to make really hard decisions about what price we're going to pay. In places like New York City, Seattle, Boston, we are reaching the capacity of our healthcare system and may soon overrun it.
How will this affect rural communities, like yours in West Virginia?
We have to consider how we can prevent the spread to rural areas of the United States. Where we are in West Virginia, we serve people from all walks of life, but are primarily in underserved areas. We have clinics in formerly very heavy coal producing areas, and we deal with a lot of chronic illnesses like heart disease, lung diseases, and diabetes.
The Kaiser Family Foundation recently did a study evaluating at-risk populations for a pandemic.
West Virginia had 51% of its population over the age of 20 at risk for complications. The national average is 41%.
We are not only dealing with individual human beings that have chronic medical illnesses, but also Hepatitis B and C, and HIV cases related to intravenous drug use. In addition to these problems we now have to address a pandemic that strains our own internal capacity. What's most concerning to me is that we are working with very high-risk populations for complications from coronavirus.
How do you prepare for a pandemic in the face of that reality?
As the medical director, my effort in the last couple of weeks has been almost solely focused on preparing Cabin Creek Health Systems for a pandemic, which includes 11 sites in Kanawha County. We've been preparing to try to segregate people with respiratory symptoms away from other patients, moving toward deferring visits that do not require an in person visit, and trying to shift more to telephone and telemedicine to care for patients. We will still need to see patients in person for a variety of issues.
Yesterday I was in clinic for the first time in a while and actually swabbed someone for COVID-19. He had been on a cruise with two other family members with upper respiratory symptoms. I tested him for COVID-19 after donning personal protective equipment and administered the nasopharyngeal swab. We will find out the results in a few days.
This has been the pressing issue for me: worrying about a pandemic with the background of people in a state that ranks first in almost every bad category of health indicators, and usually bottom three for every good category of health outcomes.
It's a real challenge because our population is sicker than most.
If it hits here the way it does in other places, we're soon going to be out of ICU capacity and hospital bed capacity. There may be difficult triage decisions made for people to access care.
One advantage I think we have is that we are rural. People either live on ridge tops or they live in the hollows and that tends to create its own capability for social distancing. Whether you're in rural America or urban America, you're going to do pretty well if you practice social distancing. The question is whether or not we have the discipline to maintain social distancing, and biting the bullet on economic damage that it is going to do.
The case number is currently low in West Virginia. How are people responding in a place that is not visibly taken by the virus?
https://dhhr.wv.gov/COVID-19/Pages/default. | 39 Total Positive Cases as of 11:47PM PST 3.24.20
First of all, we don't really know how many cases there are. This is a huge blind spot everywhere in the United States, and here in West Virginia as well. While we know we have eight cases [on 3.21.20], I think everybody in public health understands that the real number of cases out there is much, much higher.
We are really like soldiers on a battlefield in a fog. We know the enemy is out there, but we don't know their strength in numbers.
I think many people here, from what I can gather from social media, are still in disbelief that this is as bad as it was because of messaging that came from some conservative media sources and the message that was coming from the White House for some time. I think the lingering effect of that is that there are many people who don't take it seriously. Two days ago, I went to a supermarket and I still saw people walking out with rolls of toilet paper under each arm, which I can't comprehend because there is no toilet paper shortage. And instead of just getting in and out with their toilet paper, I saw people congregating in the parking lot having discussions, which is an anathema to what we should be doing right at the moment.
Right. There is something strange about going to a store right now, without knowing what the future looks like – even with all the information I have, I pause and think, do I need more stuff?
Definitely. That attitude can be very contagious.
When we look to countries ahead of us chronologically, how can we use their experiences as a model?
If we stop and take a look around the world and how different people handled it, we're going to find success stories that could help lead us to a better place. One is China.
China of course, made the fatal flaw of suppressing the information on the virus, and we're all suffering because of it.
Because they have much more authority to enforce disciplined public health measures than we do in Western democracies, they were able to clamp down very rigidly on their population. This sort of radical social distancing and enforcement of quarantine seems to have worked in China. I think they may be out of the woods, depending on how they manage the subsequent waves of disease that are inevitably coming. While there may be no more new domestic cases, China is very connected to the rest of the world and can import cases.
Then you have South Korea. South Korea was an early leader in terms of number of cases and number of deaths. The Korean CDC is a capable and intelligent organization. They rapidly deployed testing kits and identified the people at risk and tested them. Whoever was positive, was isolated immediately. This is very widespread, population-based testing, an aggressive management of the disease seems to be flattening the curve in South Korea. They seem to be a model we can follow. In general, South Korea looks a lot more like Western countries politically, than they do a rigid, authoritarian country like the People’s Republic of China.
If we want to really get a hold of this, we have to expand testing radically.
Part of this is buying time everyday so we can slow the spread and allow industry to catch up, to allow research to catch up, and to implement widespread testing. This will really make a major difference in our response.
What can we expect given our current reality?
My concern is what frequently happens when you start to get success is that you become complacent. I anticipate we will eventually succeed in controlling this in some manner or another. The reality of the situation is going to hit home, even for the people who are still out there in denial. I anticipate that over the summer months, the disease will wane and give us the sense of security that we've kind of got this thing under control.
I really worry about what's going to happen in the fall if we let universities reconvene and schools reconvene.
People from all over the country are going to descend on campuses and share their viruses, which happens every year. This could reignite the whole situation. That’s why we really need to have a much tighter testing regimen in place by fall. We can buy time through the summer months and become very aggressive about developing testing, including point of care testing. There's a difference between what we're doing now with testing, which is the nasopharyngeal swabs and sending it off to a lab for evaluation, and things like the rapid flu test, which we can do in an office setting in about 30-45 minutes. We have a similar test already for influenza. In those cases we test, keep the patient in the office and tell them whether or not they have influenza. A similar test for coronavirus would be ideal. I believe it could be a prerequisite that the student body and the faculty would have to be tested and be certain they were negative before returning to campus.
Coronaviruses are not new to the United States. There are at least three other coronaviruses that show up in our communities and present like a common cold. What we are concerned about here is the more pathogenic and dangerous COVID-19 virus. We need a test that could be easily administered, and then we need to be able to isolate the positive cases that do come back away from the population.
In some ways, it's like when you think you've put out the forest fire, but those smoldering embers lying in wait can help reignite the fire all over again. My greater concern over the long term is that we become complacent and that this disease makes a resurgence in the fall months.
Data is finally emerging, but I feel like data is only as useful as the person interpreting it. How are you reading what comes out of China, Italy, or South Korea?
Data is also only as good as the people collecting it, and what they are collecting.
The Chinese data and the South Korean data especially, are the best gauges for what the real case fatality rate is.
There's a lot that comes into play here. So again, South Korea has done much broader testing, they're identifying the less symptomatic cases, as well as the extremely ill cases. The last time I looked, the fatality rate was 0.8%.
Italy on the other hand, is not doing the broad-based testing. It could be that their case fatality rate is in fact higher because they can't deliver the level of care required to every person coming in because they're making triage decisions – literally who's going to live and die. Because they are in this dire situation where they have outstripped their capacity, people who might have survived previously are no longer given that opportunity because there's not enough intensive care unit beds, ventilators, and intensive care unit staff. We have to look at all the data from a wide variety of angles.
What is the real number? I'm looking at the South Korean model as the most accurate, even though it's probably not perfect. If we can drive the case fatality rate down to 0.8% that means: a), we're doing enough testing and b), we're maintaining our capacity to care for those who are extremely ill.
What else do we need to pay attention to right now?
One is that we have to plan ahead for vaccine distribution. We know when this vaccine is finally produced, we are not going to have enough for everybody, and it's going to be available gradually as production increases. People like health care workers and first responders are going to be among the first in line. People at highest risk of disease are going to be next in line. We have to begin to communicate those priorities well in advance, in order to prevent public panic.
Think about people trying to get vaccine when you see people hoarding toilet paper.
The communication has to be clear.
One of the most touching things I saw in relation to pandemic preparedness was a mass vaccination on Saipan in the Commonwealth of the Northern Mariana Islands. In 2007 and 2008, the Department of Defense received an excess of flu vaccine they were planning on paying a company to destroy. At the same time there were people in places like the Pacific US territories that weren't getting enough. I thought, we have this need in the Western Pacific, so why not use it? I was able to get it shipped out and used as part of the community's pandemic planning.
How do we plan for a mass vaccination?
Ultimately, that's going to come down to planning at the local level. That means local health departments and hospitals and other health organizations will have to collaborate with law enforcement to set up mass vaccination sites that may include drive-through vaccination clinics where you are.
Got it.
I wanted to mention that at the end of this, we have to ask ourselves, “How could we let our public health system fail the way it did?”
When it comes to a pandemic, you see how the system has failed because it was underfunded and under-resourced at the federal, state, and local levels for many years. We often boast that we have the best healthcare system in the world. That myth is busted if we are failing even the doctors, nurses, and other staff on the front lines of this pandemic without adequate personal protective equipment. How could this be allowed to happen when we knew that a pandemic would eventually hit?
I was just listening to NPR on the way to talk to you and I heard somebody talking about how a pandemic bears a similarity to earthquakes, another periodic natural event. If you live in Los Angeles, you know that the big one is coming sooner or later. We knew pandemics were coming. It was inevitable. And yet we were so ill prepared for this.
This is a societal failing to undervalue public health.
We have to reimagine how we view health. We have typically viewed health through the lens of health care, when we know about factors called the social determinants of health that account for 80% of a population’s health. I'm talking about things like employment, economy, education, housing, transportation. All of these things play together in the health of people. The growing homeless problem you have in Los Angeles, in San Francisco, and even here in Charleston, West Virginia is a nationwide phenomenon, and these are people who are at high risk for all kinds of bad health outcomes. We are together only as healthy as the least healthy among us. They are the weak links in the chain of health. We have to have the view that we are interconnected.
We need to be prepared for the next pandemic that will inevitably come, and look at health from a holistic perspective. At the social services, at education. All of these things are crucial determinants of health for our nation and for our planet. If we fail to do that, then we have fundamentally failed to learn the lessons of this pandemic.
You’re so right about LA – it's cognitive dissonance. It's too big to wrap your head around. Right now there’s no looking away. Hopefully we use the opportunity as you suggest.
You nailed it. This cognitive dissonance is so true. We can't ignore it, and we're all paying the price for all of the weaknesses in our chain of health, in our chain of healthcare, and in our failure to plan for the inevitable. I think it's just such a profound quote from Tom Friedman who said, “We have to manage the unavoidable to avoid the unmanageable.”
And I thought, wow, that's really the whole pandemic in a nutshell. We have to face what's clearly in front of us. We can no longer look away, otherwise, we are setting up future generations for a failure on the scale that we see today.
interviews
Observations on Media Activism
by Dr. Clark-Parsons
October 16, 2019
Dr. Clark-Parsons is a Postdoctoral Research Fellow in Activism, Communication, and Social Justice at Annenberg School for Communication at the University of Pennsylvania. Her teaching and research revolve around feminist social movements in the United States and their media practices, drawing on her own participation in and observations of contemporary feminist media campaigns. She can be reached via email at rosemary.clark@asc.upenn.edu
This interview with Dr. Rosemary Clark-Parsons was conducted and condensed by frank news and originally published on September 13, 2018.
frank: I would love to talk to you about your focus on feminist social movements and media practices. But particularly, digital media and social media, in both positive and negative ways.
Rosemary: Yeah, I'm happy to talk about that. Always.
Right now I am post-doctoral fellow in activism, communication, and social justice at the Annenberg School for Communication which is at University of Pennsylvania. I just wrapped up my PHD there over summer, and I sort of came to this research interest through a long-standing interest going back to college in gender in media. I was really interested at first in focusing my research on media representations of women, girls, and other gendered bodies.
But I found that that research area was so depressing and kind of stagnant. We know that the state of affairs when it comes to media representations of gender is pretty bad and has been pretty bad for a long time. That's where the story ends on the research side of things.
I was interested in turning toward the activists who are trying to do something with media to change the state of affairs when it comes to gender and power and representation. So, that's essentially how I got into my interest in studying activism.
frank: How did you end up combining them?
Rosemary: For me the answer came through a research method that we call ethnography which essentially involves participant observation. The data collection method comes from actually being involved in and participating in the thing that you're studying.
That meant getting involved with grassroots activist groups in the city of Philadelphia.
frank: What have you found effective in both your research and your activism?
Rosemary: A lot of my research has been focused on the fact that there are both strengths and weaknesses to using any sort of communication tools, whether we're talking about digital, or analog, or non-digital tools, for activist purposes. All of these tools have a fair amount of limitations, but a lot of the discourse in the early days of the internet was this is how the revolution is going to happen.
frank: What are those limitations?
Rosemary: One of the biggest limitations actually comes from one of the biggest strengths. Now we no longer need to have access to a big name organization, with lots of money, lots of people power, resources, and experience to launch a movement. And on the one hand, that's great. We can launch a big protest without requiring the same degree of physical organization. We don't have to be meeting for months at a time in person to organize some kind of political action whether that's a street protest or a boycott or what have you.
So, while we can launch an action really quickly, sometimes we have issues in these movements with long term struggles for social justice, with responding to new challenges as they emerge.
frank: One thing that keeps coming up in terms of effective activism is having very clearly outlined goals. With the ease of social media we can quickly gain a lot of attention but just as quickly forget the true desired outcome. How do you think people avoid that? What sort of leadership or communication does that take?
Rosemary: Yeah, that's a great question. I think that's another issue that comes from this sort of double-edged sword of doing digitally networked activism. On the one hand, if you look at hashtag campaigns, anyone can chime in and sort of bring their own personal reasons for participating to the table. I can share my story under the #MeToo hashtag, for example. But then when it comes to articulating a very clear set of, for example, policy goals, or just concrete steps toward social change, whether at the policy level or more at the cultural level, we're not seeing these movements come together to put out a mission statement. Does that make sense?
frank: Yes.
Rosemary: I think the more successful movements that we're seeing are combining the more old fashion elements of movement organizing, like meeting somehow in person together with a dedicated group of activists, organizing locally, and then also doing these sort of huge network campaigns at the same time. #MeToo is a great example of that, having both the long term struggle component led by Tarana Burke, and sort of branching off into the Time's Up movement. The Never Again movement that came out of the shootings in Florida is another great example of this as well. They're taking advantage of the participatory globally networked nature of social media platforms while also doing the difficult work on the ground to organize long term.
frank: Right. There seems to be a need for a more intense focus on the communities you're actually trying to help.
Rosemary: Yeah, I think that we especially saw this with the very impressive young activists who came out of the Stoneman Douglas shootings. You could see it play out in terms of the news coverage, the need for them to gain trust, not just within their local communities but to gain the trust of their audience. To gain respect of authorities on the issue of control despite the fact that they're these teenagers. Which was working against them.
I think trust, in terms of how you're received by the public, whether that's your immediate neighborhood, organizing for an issue on your block, or whether that's your national audience, as in the case of the Never Again movement, it's essential for social movements, and again requires some of that more old fashioned form of organizing. There were a couple of pieces written about how the teen activists in Stoneman Douglas came together and organized in the aftermath of the shooting. There's a story about them getting together at a slumber party at one of the activists houses and deciding “This is our strategy. This is how we handle the media. We cannot make mistakes, actually, because that will immediately be a reason to put us down. You know we already have our age working against us. We need to gain the trust of our audience."
Trust has always been a key component for a successful movement and continues to be. And it's become even trickier in our world of fake news and conspiracy theories circulating online. You really need to have some authority and gain the trust of your audience.
frank: What do you think about the commodification of cause? About activism as trend? I have a strong gut reaction when I see this stuff online, and think, I don't need to hear about x from you, but perhaps that doesn't matter and all voices added to the mix are important.
Rosemary: Yes, that's a great question. There are two big related changes I've seen with activism over the past five years. One is that it's becoming more mediated and the second is that it's becoming more personalized, like hashtag activism. All the people posting under the hashtag are united by the hashtag itself but they're sharing these very individualized, personalized stories or reasons for participating. That makes it really easy to coopt and commodify. When it's just this personal individual act, it's very easy to take that up and turn it into something that you can sell.
We saw this unfortunately, and unbelievably to me, with the #MeToo movement. There were makeup lines branding their products with the #MeToo hashtag. We saw jewelry and clothing lines popping up around the campaign, even a whole bunch of different mobile apps. And they certainly have somewhat of a positive valance. We want to see these issues represented within popular culture, within consumer culture. But there's the danger there of suggesting that what's needed to solve a problem as big as sexual violence and sexual harassment is just this individual act of buying something rather than collectively organizing for structural change.
frank: If you have a large social presence or voice, and you want to be involved, how do you avoid personalizing everything, or avoid taking away from the movement's goals?
Rosemary: I don't think that there's necessarily anything inherently wrong in personalizing your involvement. Feminists in the U.S. have been saying the personal is political since the 1960s. The issue is keeping that connection between the personal and the political, reminding the people who are following you that your personal story is connected back to this structural issue, not just you. It's part of this, in the case of #MeToo, global issue of sexual violence.
frank: Do you feel like people, especially women who have a large voice or public presence, should feel a responsibility to contribute to the conversation, or do you think that we put too much pressure on people to fall into the categories and narratives that we would like to see them in?
Rosemary: One of the very valid concerns about the #MeToo movement, for example, is that we're putting a lot of pressure on not just women but anyone who has experienced sexual violence and harassment to come forward and tell their story. And one concern there is all of the focus is on the survivors and the victims rather than on actually holding accountable the people who are responsible for this behavior and for these assaults in some cases.
We see a lot of hype in the media, a lot of excitement, however misguided, when someone comes forward and says yet another big name renowned celebrity has committed some act of sexual misconduct, and then it becomes about the interpersonal drama.
Rather than the fact that this is huge problem that exists way beyond the scope or the story of two people. I think that there's a danger there in encouraging high profile people to continue to come forward, but at the same time, it's yet another one of these double-edged sword situations. When they come forward, they also encourage other people to feel less shame about their own experiences.
So, it's one of those sort of gray zone situations, to me.
frank: What do you think is next in terms of feminism and feminist movements? What do you think is the next big push and focus?
Rosemary: I think what seems to be on the horizon for feminism in the U.S. right now is figuring out how to take what has been for several years now a very visible surge of feminist activism that has been very much focused on the personal, on everyday fight the power and oppression, everyday encounters with sexual violence, and channeling that into more sustainable, long-lasting, efforts for social change, at the policy level, at the level of more formal institutions of power.
Because on the one hand, we're living in a moment where feminism is everywhere. We can, as we've talked about, buy feminist branded products in the store.
We live in this moment, where it's everywhere, but we also live in a moment where the reality is that Donald Trump is president and we're seeing a systematic roll back of women's rights, of civil rights, the rights in marginalized communities, on a near daily basis. So, there's a disconnect there.
Somehow, we have risen to this high level of visibility within popular culture, but we're not at the same time able to create these longer lasting institutional changes. I'm hopeful that that's going to shift, that the disconnect is going to come together a little bit more. We're seeing a lot of headlines heralding what they're calling the Year of Women. A lot of feminist candidates have been running for different levels of political office. The next big issue for these movements is figuring out how to turn that energy, turn that focus, on everyday sorts of injustice, everyday sites of power, and channel that into more institutional long lasting forms of change.
frank: What new policy for women's equality are you looking for? Or, is the change you're more interested in cultural?
Rosemary: I think we need to not lose sight of either one. I don't want the pendulum to swing too far into the direction of institutional policy and let go of some of the great work feminist activists have been doing around these more every day social forms of change. We're now more aware than ever, I think of sexual harassment as a social issue, but I think they need to be paired together. I would love to see the same amount of energy and the same amount of success in the area of shoring up our policies around sexual harassment, shoring up the resources we have for survivors who are seeking legal recourse or who are seeking some kind of transformative justice within their particular cases. We know that this is an issue that is everywhere and that's undeniable, but the question becomes now what?
frank: What do you feel is being overlooked right now? In terms of what your research is focused on.
Rosemary: This has been the common thread, I think, in what we've talked about already, but one point that I feel I try to make in my research is that we need to be paying close attention to this shift away from a time when big name formal organizations structured with movements which came with its own set of pros and cons. There are organizational resources on the one hand, and dedicated leaders, but then there are also all sorts of exclusion and gatekeepers filtering out who gets to participate and whose voices are heard.
We're seeing a shift away from that and towards these media platforms, actually becoming the way that movements are structured. So, whereas you might have had in the past, organizations controlling a movement's communication, today, the actual message itself, whether it's a hashtag, or whether it's a platform - these forms of media are at the center of a lot of social movements today and that comes with a whole range of affordances and limitations. I think that's a major shift that's being overlooked in conversations about the future of social organizing in the U.S. and one that I try to highlight a lot in my own work.